Reactions 1345 - 2 Apr 2011

SRopivacaine

Horner’s syndrome and hemidiaphragmaticparesis: 2 case reports

A 40-year-old woman and a 64-year-old man developedHorner’s syndrome during high thoracic paravertebralblock with ropivacaine; the woman also developedipsilateral hemidiaphragmatic paresis. In both patients, aneedle was placed posterior to the parietal pleura and, afternegative aspiration, a bolus of 0.75% ropivacaine 5mL wasinjected followed by a second, 10mL bolus; a catheter wasthen threaded, and the placement was confirmed byinjection of 0.75% ropivacaine 5mL through the catheter.

The woman underwent paravertebral block for pain dueto trauma, and experienced numbness and loss of motorfunction in her left arm 30 minutes later; her pain score haddecreased from 8 to 1. Examination revealed absentpinprick sensation in multiple nerve distributions of her leftarm, ipsilateral loss of cold sensation in her T1–8dermatomes, and ipsilateral Horner’s syndrome. A chest x-ray revealed spreading radio-opaque dye from theparavertebral space toward and around the left-sidedbrachial plexus, and a new-onset elevated left-sidedhemidiaphragm. An ultrasound of her left-sided diaphragmidentified paradoxical left diaphragm movement.Ultrasound of the phrenic nerve showed no evidence oflocal anaesthetic around the phrenic nerve or anterior to heanterior scalene muscle. She was informed about thisinfrequent ADR, and received a 0.2% ropivacaine infusionat a rate of 10 mL/h; diaphragmatic movement and pinpricksensation in her left arm were diminished during theinfusion. The catheter was removed after 6 days, and leftarm sensation and motor function recovered. One daylater, diaphragmatic movement had normalised. She wasdischarged 2 days later.

The man underwent upper thoracic necrotectomy undergeneral anaesthesia with preoperative paravertebral block.After surgery, he reported numbness and loss of motorfunction in his left arm [time to onset not stated].Investigations identified loss of pinprick sensation inmultiple left nerve distributions, ipsilateral Horner’ssyndrome and loss of cold sensation in dermatomes T1–6.A chest x-ray identified spreading of radio-opaque dyetoward and around the ipsilateral brachial plexus, and alongthe brachial plexus toward the axilla. He was informedabout this infrequent ADR, and began receiving an infusionof 0.2% ropivacaine 10 mL/h. pinprick sensation wasdiminished in his left arm during the infusion. The catheterwas removed after 2 days. His left arm’s sensation andmotor function normalised, and Horner’s syndromeresolved. He was discharged the next day.

Author comment: "Horner syndrome, as found in ourpatients, is presumed to result from spread of local anestheticto the ipsilateral stellate ganglion or the preganglionicfibers. . . In our opinion, the hemidiaphragmatic paresisfound in our patient is explained by spread of the localanesthetic toward the phrenic nerve becausehemidiaphragmatic excursions returned to reference rangeafter ending the ropivacaine 0.2% infusion."Renes SH, et al. Ipsilateral brachial plexus block and hemidiaphragmatic paresis asadverse effect of a high thoracic paravertebral block. Regional Anesthesia and PainMedicine 36: 198-201, No. 2, Mar-Apr 2011. Available from: URL: http://dx.doi.org/10.1097/aap.0b013e31820d424c - Netherlands 803052142

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Reactions 2 Apr 2011 No. 13450114-9954/10/1345-0001/$14.95 © 2010 Adis Data Information BV. All rights reserved